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Personal Choice 65SM PPO

H3909Y0041_H3909_PC_20_77038_M Accepted 9/2/2019

2020Summary of BenefitsEffective January 1, 2020 through December 31, 2020

• Personal Choice 65SM Prime Rx PPO• Personal Choice 65SM Medical-Only PPO• Personal Choice 65SM Rx PPO

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This Summary of Benefits booklet gives you a summary of what Personal Choice 65SM

Prime Rx PPO, Personal Choice 65SM Medical-Only PPO, and Personal Choice 65SM

Rx PPO cover and what you pay.

Personal Choice 65SM Prime Rx PPO, Personal Choice 65SM Medical-Only PPO,

and Personal Choice 65SM Rx PPO are Medicare Advantage PPO (Preferred Provider

Organization) plans. With a PPO plan, members don’t have to choose a PCP and can

go to doctors in or out of the plan’s network. If members use out-of-network doctors,

hospitals, or other health care providers, they will pay more for their services.

If you want to compare our plans with other available Medicare health plans,

ask the other plan(s) for their Summary of Benefits booklet. Or, use the Medicare Plan

Finder at www.medicare.gov.

If you want to know more about the coverage and costs of Original Medicare,

look in your current “Medicare and You” handbook. View it online at

www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24

hours a day, 7 days a week. TTY users should call 1-877-486-2048.

Sections of this booklet

• Monthly Premium, Deductible, Limits on How Much You Pay

for Covered Services

• Covered Medical and Hospital Benefits

• Prescription Drug Benefits for Personal Choice 65SM Prime Rx PPO

and Personal Choice 65SM Rx PPO• Optional Supplemental Benefits (Choice and Choice Plus Programs)

You must pay an extra premium for these benefits.

Who can join?

To join Personal Choice 65SM Prime Rx PPO, Personal Choice 65SM Medical-Only PPO,

and Personal Choice 65SM Rx PPO, you must be entitled to Medicare Part A, be enrolled

in Medicare Part B, and live in our service area.

The service area for Personal Choice 65SM Medical-Only PPO is Bucks and Philadelphia

counties in Pennsylvania.

The service area for Personal Choice 65SM Prime Rx PPO and Personal Choice 65SM Rx

PPO is Bucks, Chester, Delaware, Montgomery, and Philadelphia counties

in Pennsylvania.

This booklet gives you a summary of what we cover and what you pay. It doesn’t list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, call us and ask for the Evidence of Coverage or go online at www.ibxmedicare.com.

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Which doctors, hospitals, and pharmacies can I use?

Personal Choice 65SM Prime Rx PPO, Personal Choice 65SM Medical-Only PPO,

and Personal Choice 65SM Rx PPO have a network of doctors, hospitals, pharmacies,

and other providers. If you use the providers that are not in our network, a higher cost-

sharing may apply. Personal Choice 65SM Prime Rx PPO and Personal Choice 65 Rx

PPO have a preferred pharmacy network; cost-sharing for drugs may vary depending on

the pharmacy you use. To view our list of network providers and pharmacies (Provider/

Pharmacy Directory),

please visit www.ibxmedicare.com.

Personal Choice 65SM Prime Rx PPO and Personal Choice 65SM Rx PPO cover

Part D drugs. In addition, the plans cover Part B drugs such as chemotherapy

and some other drugs administered by your provider. You can see our complete plan

Formulary (List of Covered Drugs) and any restrictions on our website,

www.ibxmedicare.com.

Personal Choice 65SM Medical-Only PPO covers Part B drugs, including chemotherapy

and some other drugs administered by your provider.

However, the plan does not cover Part D prescription drugs.

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Monthly Plan PremiumPersonal Choice 65SM Prime Rx PPOIf you live in… And you have…

Personal Choice 65SM

Prime Rx PPOPersonal Choice 65SM Prime Rx PPO with Choice


Prime Rx PPO with Choice Plus

You pay…

Chester, Delaware, or Montgomery County

$0 $12 $25

Bucks or Philadelphia Coun-ty

$0 $12 $25

Personal Choice 65SM Medical-Only PPOIf you live in… And you have…

Personal Choice 65SM Medical-Only PPO


Medical-Only PPO with Choice


Medical-Only PPO with Choice Plus

You pay…


n/a n/a n/a


$184 $196 $209

Personal Choice 65SM Rx PPOIf you live in… And you have…

Personal Choice 65SM Rx PPO

Personal Choice 65SM Rx PPO with Choice

Personal Choice 65SM Rx PPO with Choice Plus

You pay…


$159 $171 $184


$288 $300 $313

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Prime Rx PPO Personal Choice 65SM

Medical-Only PPO Personal Choice 65SM

Rx PPO

Deductible This plan has a $1,000 deductible for covered medi-

cal services received from out-of-network providers.

Does not apply to preventive services or supplemental

benefits.

This plan does not have a deductible for covered Part

D drugs.

This plan does not have a deductible for covered medical

services.

This plan does not have a deductible for covered

medical services or Part D prescription drugs.

Maximum Out-of-Pocket(the amounts you pay for your premium, Part D prescription drugs and some medical services do not count toward your maximum out-of-pocket amount)

In-Network: $6,700 each year

Our plan has a yearly coverage limit for certain

in-network benefits.

Contact us for the services that apply.

Combined In-Network and Out-of-Network: $10,000 each

year





Combined In-Network and Out-of-Network: $10,000 each

year





Combined In-Network and Out-of-Network: $10,000

each year

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Covered Medical and Hospital BenefitsPersonal Choice 65SM



Rx PPO

Inpatient Hospital Coverage (1) In-Network: $250 copayment per day, days 1 through

7 per admission for Preferred Hospital

$310 copayment per day,for days 1 through 7 per

admission for Standard Hospital

You pay nothing per day for days 8 and beyond per

admission. No copayment on day of discharge.

Out-of-Network: 30% coinsurance after deductible

In-Network: $250 copayment per day for days 1

through 6 per admission



$1,500 maximum copayment

per admission

Out-of-Network: 30% coinsurance






per admission


Outpatient Hospital Coverage

• Ambulatory Surgical Center (1)

• Outpatient Hospital Facility (1)

• Observation Services

In-Network: $250 copayment


In-Network: $375 copayment for a Preferred Hospital

$475 copayment for a Standard Hospital


In-Network: $375 copayment per stay for a

Preferred Hospital


Out-of-Network: 30% coinsurance per stay

after deductible





In-Network: $300 copayment per stay








Doctor’s Office Visits

• Primary Care Physician

• Specialist

In-Network: $5 copayment for Preferred

primary care physician

$20 copayment for Standard primary care physician


In-Network: $40 copayment for Preferred specialist

$50 copayment for Standard specialist










Services with a (1) may require prior authorization.

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Covered Medical and Hospital BenefitsPersonal Choice 65SM



Rx PPO

Inpatient Hospital Coverage (1) In-Network: $250 copayment per day, days 1 through

7 per admission for Preferred Hospital

$310 copayment per day,for days 1 through 7 per

admission for Standard Hospital









per admission







per admission


Outpatient Hospital Coverage

• Ambulatory Surgical Center (1)

• Outpatient Hospital Facility (1)

• Observation Services



In-Network: $375 copayment for a Preferred Hospital



In-Network: $375 copayment per stay for a

Preferred Hospital



after deductible













Doctor’s Office Visits

• Primary Care Physician

• Specialist

In-Network: $5 copayment for Preferred

primary care physician

$20 copayment for Standard primary care physician


In-Network: $40 copayment for Preferred specialist

$50 copayment for Standard specialist










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Rx PPO

Preventive Care In-Network: You pay nothingOut-of-Network: 30% coinsurance

Please refer to the Evidence of Coverage for a com-plete listing of services. If you receive a separate additional non-preventive evaluation and/or service, a copayment will apply. The copayment amount depends on the provider type or place of service.

In-Network: You pay nothingOut-of-Network: 30% coinsurance

Please refer to the Evidence of Coverage for a com-plete listing of services. If you receive a separate additional non-preventive evaluation and/or service, a copayment will apply. The copayment amount depends on the provider type or place of service.


Please refer to the Evidence of Coverage for a complete listing of services. If you receive a separate additional non-preventive evaluation and/or service, a copayment will apply. The copayment amount depends on the provider type or place of service.

Emergency Care — covered worldwide Worldwide copayment outside the U.S. does not count towards the annual MOOP

In-Network: $90 copayment Not waived if admitted

Out-of-Network: $90 copayment

Not waived if admitted


Out-of-Network: $90 copaymentNot waived if admitted


Out-of-Network: $90 copaymentNot waived if admitted

Urgently Needed Services — covered worldwideWorldwide copayment outside the U.S. does not count towards the annual MOOP

In-Network and Out-of-Network: $10 copayment in a retail clinic Not waived if admitted

In-Network and Out-of-Network: $50 copayment in an urgent care center Not waived if admitted

Out-of-Network: $90 copayment per visit outside of U.S. Not waived if admitted

In-Network: $5 copayment in a retail clinic Not waived if admitted

Out-of-Network: $5 copayment in a retail clinic Not waived if admitted

In-Network: $40 copayment in an urgent care center Not waived if admitted

Out-of-Network: $40 copayment in an urgent care center Not waived if admitted

In-Network: $90 copayment per visit outside of U.S. Not waived if admitted


In-Network: $5 copayment in a retail clinic Not waived if admitted

Out-of-Network: $5 copayment in a retail clinic Not waived if admitted

In-Network: $40 copayment in an urgent care center Not waived if admitted

Out-of-Network: $40 copayment in an urgent care center Not waived if admitted

In-Network: $90 copayment per visit outside of U.S. Not waived if admitted


Diagnostic Services (1), Lab and Radiology Services (1), and X-rays

• Diagnostic Radiology Services

• Lab Services

• Diagnostic Tests and Procedures

• Outpatient X-rays

In-Network: $45 or $225 copayment depending on serviceOut-of-Network: 30% coinsurance after deductible In-Network: You pay nothing


In-Network: You pay nothingOut-of-Network: 30% coinsurance after deductible

In-Network: $45 copayment for routine radiology services Out-of-Network: 30% coinsurance after deductible for routine radiology services

In-Network: $40 or $175 copayment depending on serviceOut-of-Network: 30% coinsurance In-Network: You pay nothing



In-Network: $40 copayment for routine radiology servicesOut-of-Network: 30% coinsurance for routine radiol-ogy services

In-Network: $40 or $175 copayment depending on serviceOut-of-Network: 30% coinsurance In-Network: You pay nothing



In-Network: $40 copayment for routine radiology services Out-of-Network: 30% coinsurance for routine radiology services


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Rx PPO

Hearing Services

• Hearing Exam

• Hearing Aid

In-Network: $40 copayment for Medicare-covered

hearing exams received from a Preferred specialist

$50 copayment for Medicare-covered hearing exams

received from a Standard specialist

Out-of-Network: 30% coinsurance after deductible for

Medicare-covered hearing exams

Available with Choice or Choice Plus: In-Network and Out-of-Network: $10 copayment for

routine non-Medicare-covered hearing exams once every

year.

Available with Choice: In-Network and

Out-of-network: $699 standard digital hearing aid or

$999 premium digital hearing aid copayment per year,

per ear; 3 hearing aid fitting and evaluations every year;

up to 2 hearing aids every year, one hearing aid per ear.

Available with Choice Plus: In-Network and Out-of-

Network: $499 standard digital hearing aid or $799

premium digital hearing aid copayment per year, per

ear; 3 hearing aid fittings per year; up to 2 hearing aids

every year, one hearing aid per ear.

Routine hearing services and aids are covered when

provided by a TruHearing provider. Routine hearing

services do not count towards annual MOOP.


hearing exams

Out-of-Network: 30% coinsurance for Medi-

care-covered hearing exams

Available with Choice or Choice Plus: In-Network and Out-of-Network: $10 copayment

for routine non-Medicare-covered hearing exams

once every year.


Out-of-network: $699 standard digital hearing aid

or $999 premium digital hearing aid copayment per

year, per ear; 3 hearing aid fittings per year; up to 2

hearing aids every year, one hearing aid per ear.




ear; 3 hearing aid fittings per year up to 2 hearing

aids every year, one hearing aid per ear.




In-Network: $40 copayment for Medicare-cov-

ered hearing exams



Available with Choice or Choice Plus: In-Network

and Out-of-Network: $10 copayment for routine

non-Medicare-covered hearing exams once every

year.

Available with Choice: In-Network and Out-of-

Network: $699 standard digital hearing aid or

$999 premium digital hearing aid copayment per

year, per ear; 3 hearing aid fittings per year; up to

2 hearing aids every year, one hearing aid per ear.

Available with Choice Plus: In-Network and

Out-of-Network: $499 standard digital hearing

aid or $799 premium digital hearing aid copay-

ment per year, per ear; 3 hearing aid

fittings per year; up to 2 hearing aids every year,

one hearing aid per ear.

Routine hearing services and aids are covered

when provided by a TruHearing provider.

Routine hearing services do not count towards

annual MOOP.


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Rx PPO

Hearing Services

• Hearing Exam

• Hearing Aid


hearing exams received from a Preferred specialist

$50 copayment for Medicare-covered hearing exams

received from a Standard specialist


Medicare-covered hearing exams

Available with Choice or Choice Plus: In-Network and Out-of-Network: $10 copayment for

routine non-Medicare-covered hearing exams once every

year.


Out-of-network: $699 standard digital hearing aid or

$999 premium digital hearing aid copayment per year,

per ear; 3 hearing aid fitting and evaluations every year;

up to 2 hearing aids every year, one hearing aid per ear.




ear; 3 hearing aid fittings per year; up to 2 hearing aids

every year, one hearing aid per ear.





hearing exams



Available with Choice or Choice Plus: In-Network and Out-of-Network: $10 copayment

for routine non-Medicare-covered hearing exams

once every year.


Out-of-network: $699 standard digital hearing aid

or $999 premium digital hearing aid copayment per

year, per ear; 3 hearing aid fittings per year; up to 2

hearing aids every year, one hearing aid per ear.




ear; 3 hearing aid fittings per year up to 2 hearing

aids every year, one hearing aid per ear.




In-Network: $40 copayment for Medicare-cov-

ered hearing exams



Available with Choice or Choice Plus: In-Network

and Out-of-Network: $10 copayment for routine

non-Medicare-covered hearing exams once every

year.

Available with Choice: In-Network and Out-of-

Network: $699 standard digital hearing aid or

$999 premium digital hearing aid copayment per

year, per ear; 3 hearing aid fittings per year; up to

2 hearing aids every year, one hearing aid per ear.

Available with Choice Plus: In-Network and

Out-of-Network: $499 standard digital hearing

aid or $799 premium digital hearing aid copay-

ment per year, per ear; 3 hearing aid

fittings per year; up to 2 hearing aids every year,

one hearing aid per ear.

Routine hearing services and aids are covered

when provided by a TruHearing provider.

Routine hearing services do not count towards

annual MOOP.

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Rx PPO

Dental Services In-Network: $40 copayment for non-routine Medicare-covered dental services in a Preferred specialist office; $50 copayment for Medicare-covered dental services received from a Standard specialist

Out-of-Network: 30% coinsurance after deductible for non-routine Medicare-covered dental services in a specialist office

Available through Choice: In-Network: $10 copayment for routine non-Medicare-covered exam and cleaning every six months

$0 copay for 1 set of dental bite-wing x-rays every year. Full mouth x-rays (panoramic) not covered

50% coinsurance for restorative services, endodontics, periodontics, and extractions

Out-of-Network: 80% coinsurance for routine non-Medicare-covered dental services

80% coinsurance for restorative services, endodontics, periodontics, and extractions

$500 combined plan allowance every year for restorative dental services, endodontics, periodontics, and extractions.

Prosthodontics and oral surgery are not covered

Available through Choice Plus: In-Network: $0 copayment for routine non-Medicare-covered exam and cleaning every six months


50% coinsurance for restorative services, endodontics, periodontics, extractions, prosthodontics, and oral surgery

$1500 combined in- and out-of-network plan allowance every year for restorative services, endodontics, periodontics, extractions, prosthodontics, and oral surgery


80% coinsurance for restorative services, endodontics, periodontics, extractions, prosthodontics, and oral surgery

In-Network: $40 copayment for non-routine Medi-care-covered dental services in a specialist office

Out-of-Network: 30% coinsurance for non-routine Medicare-covered dental services in a specialist office

Available through Choice: In-Network: $10 copay-ment for routine non-Medicare-covered exam and cleaning every six months

$0 copayment for 1 set of dental bite-wing x-rays ev-ery year. Full mouth x-rays (panoramic) not covered

50% coinsurance for restorative services, endodon-tics, periodontics, and extractions

Out-of-Network: 80% coinsurance for routine non-Medicare-covered dental services and dental X-rays

80% coinsurance for restorative services, endodon-tics, periodontics, and extractions

$500 combined plan allowance every year for re-storative dental services, endodontics, periodontics, and extractions.




50% coinsurance for restorative services, endodon-tics, periodontics, extractions, prosthodontics, and oral surgery


$1500 combined in- and out-of-network plan allow-ance every year for restorative services, endodontics, periodontics, extractions, prosthodontics, and oral surgery

80% coinsurance for restorative services, endodon-tics, periodontics, extractions, prosthodontics, and oral surgery

In-Network: $40 copayment for non-routine Medicare-covered dental services in a specialist office

Out-of-Network: 30% coinsurance for non-rou-tine Medicare-covered dental services in a spe-cialist office

Available through Choice: In-Network: $10 co-payment for routine non-Medicare-covered exam and cleaning every six months

$0 copayment for 1 set of dental bite-wing x-rays ev-ery year. Full mouth x-rays (panoramic) not covered

50% coinsurance for restorative services, end-odontics, periodontics, and extractions

Out-of-Network: 80% coinsurance for routine non-Medicare-covered dental services and dental X-rays

80% coinsurance for restorative services, end-odontics, periodontics, and extractions

$500 combined plan allowance every year for restorative dental services, endodontics, periodon-tics, and extractions.




50% coinsurance for restorative services, end-odontics, periodontics, extractions, prosthodon-tics, and oral surgery


$1500 combined in- and out-of-network plan allowance every year for restorative services, endodontics, periodontics, extractions, prostho-dontics, and oral surgery

80% coinsurance for restorative services, end-odontics, periodontics, extractions, prosthodon-tics, and oral surgery

16 17Services with a (1) may require prior authorization.




Rx PPO

Vision Services In-Network: $40 copayment for Medicare-covered

eye exams received from a Preferred specialist, $50

copayment for Medicare-covered eye exams received

from a Standard specialist; $0 copayment for diabetic

retinal eye exam and $0 copayment for Medicare-

covered glaucoma screening; $0 copayment for one pair

of Medicare-covered eyeglasses or contact lenses after

cataract surgery


Medicare-covered eye exams, diabetic retinal exam,

glaucoma screening and for one pair of eyeglasses or

contact lenses after cataract surgery

Available through Choice or Choice Plus: $10 copayment for routine eye exam every year; 1 pair

of eyeglass frames and lenses or one pair of contact

lenses are covered in full every year if purchased from

the Davis Vision Collection;

$150 combined in- and out-of-network plan allowance

every year for all other eyewear

(glasses, lenses or contacts) purchased at a

Davis Vision provider.

$200 combined in- and out-of-network allowance every

year for eyewear (glasses and lenses) purchased from

Visionworks.

Routine vision services do not count towards the annual

MOOP.


In-Network: $40 copayment for Medicare-covered eye

exams; $0 copayment for diabetic retinal eye exam and

$0 copayment for Medicare-covered glaucoma screening;

$0 copayment for one pair of Medicare-covered

eyeglasses or contact lenses after cataract surgery

Out-of-Network: 30% coinsurance for Medicare-covered

eye exams, diabetic retinal exam, glaucoma screening and

for one pair of eyeglasses or contact lenses after cataract

surgery










every year for eyewear (glasses and lenses) purchased

from Visionworks.


MOOP.



exams; $0 copayment for diabetic retinal eye exam and $0

copayment for Medicare-covered glaucoma screening; $0

copayment for one pair of Medicare-covered eyeglasses or



eye exams, diabetic retinal exam, glaucoma screening

and for one pair of eyeglasses or contact lenses after

cataract surgery

Available through Choice or Choice Plus: $10 copayment for routine eye exam every year;

1 pair of eyeglass frames and lenses or one pair

of contact lenses are covered in full every year

if purchased from the Davis Vision Collection;







from Visionworks.

Routine vision services do not count towards the

annual MOOP.


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Rx PPO

Vision Services In-Network: $40 copayment for Medicare-covered

eye exams received from a Preferred specialist, $50

copayment for Medicare-covered eye exams received

from a Standard specialist; $0 copayment for diabetic

retinal eye exam and $0 copayment for Medicare-

covered glaucoma screening; $0 copayment for one pair

of Medicare-covered eyeglasses or contact lenses after

cataract surgery


Medicare-covered eye exams, diabetic retinal exam,

glaucoma screening and for one pair of eyeglasses or










$200 combined in- and out-of-network allowance every

year for eyewear (glasses and lenses) purchased from

Visionworks.


MOOP.



exams; $0 copayment for diabetic retinal eye exam and

$0 copayment for Medicare-covered glaucoma screening;

$0 copayment for one pair of Medicare-covered

eyeglasses or contact lenses after cataract surgery


eye exams, diabetic retinal exam, glaucoma screening and

for one pair of eyeglasses or contact lenses after cataract

surgery











from Visionworks.


MOOP.



exams; $0 copayment for diabetic retinal eye exam and $0

copayment for Medicare-covered glaucoma screening; $0

copayment for one pair of Medicare-covered eyeglasses or



eye exams, diabetic retinal exam, glaucoma screening

and for one pair of eyeglasses or contact lenses after

cataract surgery

Available through Choice or Choice Plus: $10 copayment for routine eye exam every year;

1 pair of eyeglass frames and lenses or one pair

of contact lenses are covered in full every year

if purchased from the Davis Vision Collection;







from Visionworks.

Routine vision services do not count towards the

annual MOOP.


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Rx PPO

Mental Health Services

• Inpatient Mental Health Care (2)

• Outpatient Therapy (Group and Individual)

• Outpatient Substance Abuse Services (Group and Individual)

• Partial Hospitalization (2)

In-Network: $250 copayment per day for Preferred

Hospital for days 1 through 5 per admission

$310 copayment per day for Standard Hospital for days 1


You pay nothing per day for days 6 and beyond


190-day lifetime maximum in a mental health facility

In-Network: $40 copayment per therapy session




In-Network: $40 copayment per visit


In-Network: $250 copayment per day for days

1 through 6 per admission.



$1,500 maximum copayment per admission









through 6 per admission.

You pay nothing per day for days 7 and beyond Out-of-Network: 30% coinsurance

$1,500 maximum copayment per admission 190-day lifetime maximum in a mental health facility

In-Network: $40 copayment per therapy session Out-of-Network: 30% coinsurance





Skilled Nursing Facility (1) In-Network: You pay nothing per day for days 1 through 20 $165 copayment per day for days 21 through 100 per admissionOut-of-Network: 30% coinsurance after deductible per day for days 1 through 100100 days per benefit period

In-Network: You pay nothing per day for days 1 through 20$165 copayment per day for days 21 through 100 per admissionOut-of-Network: 30% coinsurance per day for days 1 through 100100 days per benefit period

In-Network: You pay nothing per day for days 1 through 20 $165 copayment per day for days 21 through 100 per admissionOut-of-Network: 30% coinsurance per day for days 1 through 100100 days per benefit period

Physical Therapy In-Network: $30 copayment per visit Out-of-Network: 30% coinsurance per visit after deductible

In-Network: $20 copayment per visitOut-of-Network: 30% coinsurance per visit

In-Network: $20 copayment per visit Out-of-Network: 30% coinsurance per visit

Ambulance (1) $300 copayment for a one-way trip


Non-emergency ambulance services require prior

authorization

$175 copayment for a one-way trip



authorization




authorization

Transportation Not covered Not covered Not covered

Services with a (1) may require prior authorization. (2) Prior authorization is required by Magellan Behavioral Health.

18 19




Rx PPO

Mental Health Services

• Inpatient Mental Health Care (2)

• Outpatient Therapy (Group and Individual)

• Outpatient Substance Abuse Services (Group and Individual)

• Partial Hospitalization (2)

In-Network: $250 copayment per day for Preferred

Hospital for days 1 through 5 per admission

$310 copayment per day for Standard Hospital for days 1











In-Network: $250 copayment per day for days

1 through 6 per admission.



$1,500 maximum copayment per admission









through 6 per admission.

You pay nothing per day for days 7 and beyond Out-of-Network: 30% coinsurance

$1,500 maximum copayment per admission 190-day lifetime maximum in a mental health facility

In-Network: $40 copayment per therapy session Out-of-Network: 30% coinsurance





Skilled Nursing Facility (1) In-Network: You pay nothing per day for days 1 through 20 $165 copayment per day for days 21 through 100 per admissionOut-of-Network: 30% coinsurance after deductible per day for days 1 through 100100 days per benefit period

In-Network: You pay nothing per day for days 1 through 20$165 copayment per day for days 21 through 100 per admissionOut-of-Network: 30% coinsurance per day for days 1 through 100100 days per benefit period

In-Network: You pay nothing per day for days 1 through 20 $165 copayment per day for days 21 through 100 per admissionOut-of-Network: 30% coinsurance per day for days 1 through 100100 days per benefit period

Physical Therapy In-Network: $30 copayment per visit Out-of-Network: 30% coinsurance per visit after deductible

In-Network: $20 copayment per visitOut-of-Network: 30% coinsurance per visit

In-Network: $20 copayment per visit Out-of-Network: 30% coinsurance per visit

Ambulance (1) $300 copayment for a one-way trip



authorization




authorization




authorization

Transportation Not covered Not covered Not covered





Rx PPO

Medicare Part B Drugs (1) In-Network: 20% coinsurance for Part B drugs such as

chemotherapy drugs

Out-of-Network: 30% coinsurance for Part B drugs such

as chemotherapy drugs

For a description of the types of drugs available under

Part B, see your Evidence of Coverage

In-Network: 20% coinsurance for Part B drugs such as

chemotherapy drugs





In-Network: 20% coinsurance for Part B drugs such


Out-of-Network: 30% coinsurance for Part B drugs

such as chemotherapy drugs



Prescription Drug Benefits (Part D)Part D Prescription Drug Benefits are available for members of Personal Choice 65 Rx PPO and Personal Choice 65 Prime Rx PPO. This benefit is not available for members of Personal Choice 65SM Medical-Only PPO.




Rx PPO

Initial Coverage Stage You pay the following until your total yearly drug costs

reach $4,020. “Total yearly drug costs” are the total drug

costs paid by both you and our Part D plan.

You may get your drugs at network retail pharmacies and

mail-order pharmacies.

Cost-sharing may change depending on the pharmacy

you choose and when you move into each stage of your

Part D benefits. You may fill your prescriptions at

either a preferred or standard pharmacy. Tier 1 and 2

prescriptions (which include most generic drugs) will have

lower copayments when you have them filled at preferred

pharmacies. For information, please review the Personal

Choice 65SM Prime Rx PPO Evidence of Coverage.

Part D prescription drugs are not available with this

plan.

You pay the following until your total yearly drug costs

reach $4,020. “Total yearly drug costs” are the total

drug costs paid by both you and our Part D plan.

You may get your drugs at network retail pharmacies

and mail-order pharmacies.


you choose and when you move into

each stage of your Part D benefits. You may fill

your prescriptions at either a preferred or

standard pharmacy. Tier 1 and 2 prescriptions (which

include most generic drugs) will have lower copayments

when you have them filled at preferred pharmacies. For

information, please review the Personal Choice 65SM

Rx PPO Evidence of Coverage.

20 21




Rx PPO

Medicare Part B Drugs (1) In-Network: 20% coinsurance for Part B drugs such as

chemotherapy drugs





In-Network: 20% coinsurance for Part B drugs such as

chemotherapy drugs





In-Network: 20% coinsurance for Part B drugs such


Out-of-Network: 30% coinsurance for Part B drugs

such as chemotherapy drugs



Prescription Drug Benefits (Part D)Part D Prescription Drug Benefits are available for members of Personal Choice 65 Rx PPO and Personal Choice 65 Prime Rx PPO. This benefit is not available for members of Personal Choice 65SM Medical-Only PPO.




Rx PPO

Initial Coverage Stage You pay the following until your total yearly drug costs

reach $4,020. “Total yearly drug costs” are the total drug

costs paid by both you and our Part D plan.

You may get your drugs at network retail pharmacies and

mail-order pharmacies.


you choose and when you move into each stage of your

Part D benefits. You may fill your prescriptions at

either a preferred or standard pharmacy. Tier 1 and 2

prescriptions (which include most generic drugs) will have

lower copayments when you have them filled at preferred

pharmacies. For information, please review the Personal

Choice 65SM Prime Rx PPO Evidence of Coverage.


plan.

You pay the following until your total yearly drug costs

reach $4,020. “Total yearly drug costs” are the total

drug costs paid by both you and our Part D plan.

You may get your drugs at network retail pharmacies

and mail-order pharmacies.


you choose and when you move into

each stage of your Part D benefits. You may fill

your prescriptions at either a preferred or

standard pharmacy. Tier 1 and 2 prescriptions (which

include most generic drugs) will have lower copayments

when you have them filled at preferred pharmacies. For

information, please review the Personal Choice 65SM

Rx PPO Evidence of Coverage.

22 23




Rx PPO

Retail Cost-sharing (what you pay at a pharmacy location)

One-Month

Supply

Two-Month

Supply

Three-Month

Supply

One-Month

Supply

Two-Month

Supply

Three-Month

Supply

Tier 1 (Preferred Generic Drugs)

Preferred Pharmacy Standard Pharmacy

$2 copayment

$9 copayment

$4 copayment

$18 copayment

$4 copayment

$27 copayment


plan.

$1 copayment

$9 copayment

$2 copayment

$18 copayment

$2 copayment

$27 copayment

Tier 2 (Generic Drugs)


$10 copayment

$20 copayment

$20 copayment

$40 copayment

$20 copayment

$60 copayment


plan.

$9 copayment

$20 copayment

$18 copayment

$40 copayment

$18 copayment

$60 copayment

Tier 3 (Preferred Brand Drugs)


$47 copayment

$47 copayment

$94 copayment

$94 copayment

$141 copayment

$141 copayment


plan.

$47 copayment

$47 copayment

$94 copayment

$94 copayment

$141 copayment

$141 copayment

Tier 4 (Non-Preferred Drugs)


$100 copayment

$100 copayment

$200 copayment

$200 copayment

$300 copayment

$300 copayment


plan.

$100 copayment

$100 copayment

$200 copayment

$200 copay-

ment

$300 copayment

$300 copayment

Tier 5 (Specialty Drugs)


33% coinsurance

33% coinsurance

33% coinsurance

33% coinsurance

33% coinsurance

33% coinsurance


plan.

33% coinsurance

33% coinsurance

33% coinsurance

33% coinsurance

33% coinsurance

33% coinsurance

Mail-Order Cost-sharing (what you pay when you order a prescription by mail)

One-Month

Supply

Two-Month

Supply

Three-Month

Supply

One-Month

Supply

Two-Month

Supply

Three-Month

Supply

Tier 1 (Preferred Generic Drugs) $2 copayment $4 copayment $4 copayment Part D prescription drugs are not available with this

plan.

$1 copayment $2 copayment $2 copayment

Tier 2 (Generic Drugs) $10 copayment $20 copayment $20 copayment Part D prescription drugs are not available with this

plan.


Tier 3 (Preferred Brand Drugs) $47 copayment $94 copayment $94 copayment Part D prescription drugs are not available with this

plan.


Tier 4 (Non-Preferred Drugs) $100 copayment $200 copayment $200 copayment Part D prescription drugs are not available with this

plan.

$100 copay-ment

$200 copay-ment

$200 copayment

Tier 5 (Specialty Drugs) 33% coinsur-ance

33% coinsur-ance

33% coinsurance Part D prescription drugs are not available with this

plan.

33% coinsur-ance

33% coinsur-ance

33% coinsurance





Rx PPO

Initial Coverage Stage If you reside in a long-term care facility, you pay the same as at a Standard retail pharmacy. This plan has a preferred pharmacy network; cost-sharing for drugs may vary depending on the pharmacy used.

You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy.

Part D prescription drugs are not available with this plan.

If you reside in a long-term care facility, you pay the same as at a Standard retail pharmacy. This plan has a preferred pharmacy network; cost-sharing for drugs may vary depending on the pharmacy used.


Coverage Gap Stage Most Medicare drug plans have a coverage gap (also called the “donut hole”). This means that there’s a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $4,020.

After you enter the coverage gap, you pay 25% of the plan’s cost for covered brand-name drugs and 25% of the plan’s cost for covered generic drugs until your costs total $6,350, which is the end of the coverage gap. Not everyone will enter the coverage gap.


Most Medicare drug plans have a coverage gap (also called the “donut hole”). This means that there’s a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $4,020.


Catastrophic Coverage Stage After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $6,350, you pay the great-er of:

• 5% of the costs, or;

• $3.60 copayment for generic (including brand drugs tested as generic) and an $8.95 copayment for all other drugs


After your yearly out-of-pocket drug costs (includ-ing drugs purchased through your retail pharmacy and through mail order) reach $6,350, you pay the greater of:



Other Medical BenefitsPodiatry Services

• Medical Condition

• Routine Foot Care (Medicare-covered)

• Routine Foot Care (non-Medicare-covered)

In-Network: $25 copayment per visit for condition treatment and $25 copayment per visit for Medicare-covered routine care Out-of-Network: 30% coinsurance per visit after deductible for condition treatment and Medicare-covered routine care

In-Network: $25 copayment per visit for non-Medicare-covered routine care, up to 6 visits each year Out-of-Network: 30% coinsurance per visit after deductible for non-Medicare-covered routine care, up to 6 visits each year

In-Network: $20 copayment per visit for condition treatment and $20 copayment per visit for Medicare-covered routine care Out-of-Network: 30% coinsurance per visit for condition treatment and Medicare-covered routine care

In-Network: $20 copayment per visit for non-Medicare-covered routine care, up to 6 visits each year Out-of-Network: 30% coinsurance per visit for non-Medicare-covered routine care, up to 6 visits each year



24 25




Rx PPO

Initial Coverage Stage If you reside in a long-term care facility, you pay the same as at a Standard retail pharmacy. This plan has a preferred pharmacy network; cost-sharing for drugs may vary depending on the pharmacy used.



If you reside in a long-term care facility, you pay the same as at a Standard retail pharmacy. This plan has a preferred pharmacy network; cost-sharing for drugs may vary depending on the pharmacy used.


Coverage Gap Stage Most Medicare drug plans have a coverage gap (also called the “donut hole”). This means that there’s a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $4,020.



Most Medicare drug plans have a coverage gap (also called the “donut hole”). This means that there’s a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $4,020.


Catastrophic Coverage Stage After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $6,350, you pay the great-er of:




After your yearly out-of-pocket drug costs (includ-ing drugs purchased through your retail pharmacy and through mail order) reach $6,350, you pay the greater of:



Other Medical BenefitsPodiatry Services

• Medical Condition

• Routine Foot Care (Medicare-covered)

• Routine Foot Care (non-Medicare-covered)

In-Network: $25 copayment per visit for condition treatment and $25 copayment per visit for Medicare-covered routine care Out-of-Network: 30% coinsurance per visit after deductible for condition treatment and Medicare-covered routine care

In-Network: $25 copayment per visit for non-Medicare-covered routine care, up to 6 visits each year Out-of-Network: 30% coinsurance per visit after deductible for non-Medicare-covered routine care, up to 6 visits each year





26 27




Rx PPO

Over-the-Counter (OTC) Items In-Network and Out-of-Network: $30 allowance per quarter for over-the-counter (OTC) items. Allowance does not carry forward to the next quarter if not used. You must use our OTC vendor, Convey, to purchase items. Items purchased from pharmacies or other retailers will not be covered. Only one order can be placed per quarter. Each order cannot exceed the $30 quarterly allowance.

In-Network and Out-of-Network: $30 allowance per quarter for over-the-counter (OTC) items. Allowance does not carry forward to the next quarter if not used. You must use our OTC vendor, Convey, to purchase items. Items purchased from pharmacies or other retailers will not be covered. Only one order can be placed per quarter. Each order cannot exceed the $30 quarterly allowance.

In-Network and Out-of-Network: $30 allowance per quarter for over-the-counter (OTC) items. Al-lowance does not carry forward to the next quarter if not used. You must use our OTC vendor, Convey, to purchase items. Items purchased from pharma-cies or other retailers will not be covered. Only one order can be placed per quarter. Each order cannot exceed the $30 quarterly allowance.

Telemedicine In-network and Out-of-network: $5 copayment for telemedicine visits. Telemedicine physicians are avail-able 24/7 365 days per year. MDLIVE must be used for telemedicine visits. MDLIVE doctors are state-li-censed physicians. Telemedicine services rendered from other providers will not be covered.

In-network and Out-of-network: $5 copayment for telemedicine visits. Telemedicine physicians are avail-able 24/7 365 days per year. MDLIVE must be used for telemedicine visits. MDLIVE doctors are state-li-censed physicians. Telemedicine services rendered from other providers will not be covered.

In-network and Out-of-network: $5 copayment for telemedicine visits. Telemedicine physicians are available 24/7 365 days per year. MDLIVE must be used for telemedicine visits. MDLIVE doctors are state-licensed physicians. Telemedicine services rendered from other providers will not be covered.

Diabetic Supplies No copayment for diabetic test strips and glucose monitors. You must use our preferred vendors Accu-Chek and OneTouch for test strips and monitors. Test strips and monitors from other vendors will not be covered.

No copayment for lancets or solutions. No copayment for diabetic shoes and inserts. No copayment for insulin pumps and related supplies. Any network vendor may be used to purchase these supplies.

Out-of-network: 30% coinsurance

No copayment for diabetic test strips and glucose monitors. You must use our preferred vendors Accu-Chek and OneTouch for test strips and monitors. Test strips and monitors from other vendors will not be covered.



No copayment for diabetic test strips and glucose monitors. You must use our preferred vendors Accu-Chek and OneTouch for test strips and monitors. Test strips and monitors from other vendors will not be covered.



Chiropractic Services

• Medical-covered (Medicare-covered)

• Routine Care (non-Medicare-covered)

In-Network: $20 copayment per visit for spinal manipulations

Out-of-Network: 30% coinsurance per visit after deductible for spinal manipulations

In-Network: $20 copayment per visit for non-Medicare-covered routine chiropractic care (up to 6 visits combined in- and out-of-network each year)

Out-of-Network: 30% coinsurance per visit after deductible for non-Medicare-covered routine chiropractic care (up to 6 visits combined in- and out-of-network each year)


Out-of-Network: 30% coinsurance per visit for spinal manipulations


Out-of-Network: 30% coinsurance per visit for non-Medicare-covered routine chiropractic care (up to 6 visits combined in- and out-of-network each year)


Out-of-Network: 30% coinsurance per visit for spinal manipulations


Out-of-Network: 30% coinsurance per visit for non-Medicare-covered routine chiropractic care (up to 6 visits combined in- and out-of-network each year)

28 29

Pre-Enrollment Checklist

Before making an enrollment decision, it is important that you fully understand our benefits and rules. If you have any questions, you can call and speak to a Member Help Team representative at 1-888-718-3333 (TTY/TDD: 711).

Understanding the Benefits

Review the full list of benefits found in the Evidence of Coverage (EOC), especially for those services for which you routinely see a doctor. Visit www.ibxmedicare.com or call 1-888-718-3333 (TTY/TDD: 711) to view a copy of the EOC.

Review the provider directory (or ask your doctor) to make sure the doctors you see now are in the network. If they are not listed, it means you will likely have to select a new doctor.

Review the pharmacy directory to make sure the pharmacy you use for any prescription medicines is in the network. If the pharmacy is not listed, you will likely have to select a new pharmacy for your prescriptions.

Understanding Important Rules

In addition to your monthly plan premium, you must continue to pay your Medicare Part B premium. This premium is normally taken out of your Social Security check each month.

Benefits, premiums and/or copayments/coinsurance may change on January 1, 2021.

Our plan allows you to see providers outside of our network (non-contracted providers). However, while we will pay for covered services provided by a non-contracted provider, the provider must agree to treat you. Except in an emergency or urgent situation, non-contracted providers may deny care. In addition, you will pay a higher copay for services received by non-contracted providers.

28 29

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30 31

Y0041_HM_17_47643 Accepted 10/14/2016 Taglines as of 10/14/2016

Language Assistance Services

Spanish: ATENCIÓN: Si habla español, cuenta con servicios de asistencia en idiomas disponibles de forma gratuita para usted. Llame al 1-800-275-2583 (TTY: 711).

Chinese: 注意：如果您讲中文，您可以得到免费的语言

协助服务。致电 1-800-275-2583。 Korean: 안내사항: 한국어를 사용하시는 경우, 언어

지원 서비스를 무료로 이용하실 수 있습니다.

1-800-275-2583 번으로 전화하십시오. Portuguese: ATENÇÃO: se você fala português, encontram-se disponíveis serviços gratuitos de assistência ao idioma. Ligue para 1-800-275-2583. Gujarati: �ચૂના: જો તમે �જુરાતી બોલતા હો, તો િન:��ુ� ભાષા સહાય સેવાઓ તમારા માટ� ��લ�� છે. 1-800-275-2583 કોલ કરો.

Vietnamese: LƯU Ý: Nếu bạn nói tiếng Việt, chúng tôi sẽ cung cấp dịch vụ hỗ trợ ngôn ngữ miễn phí cho bạn. Hãy gọi 1-800-275-2583. Russian: ВНИМАНИЕ: Если вы говорите по-русски, то можете бесплатно воспользоваться услугами перевода. Тел.: 1-800-275-2583. Polish UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-800-275-2583. Italian: ATTENZIONE: Se lei parla italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-275-2583. Arabic:

، فإن خدمات المساعدة اللغوية العربية ملحوظة: إذا كنت تتحدث اللغة .2583-275-800-1 اتصل برقملك بالمجان. متاحة

French Creole: ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-800-275-2583.

Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, magagamit mo ang mga serbisyo na tulong sa wika nang walang bayad. Tumawag sa 1-800-275-2583.

French: ATTENTION: Si vous parlez français, des services d'aide linguistique-vous sont proposés gratuitement. Appelez le 1-800-275-2583. Pennsylvania Dutch: BASS UFF: Wann du Pennsylvania Deitsch schwetzscht, kannscht du Hilf griege in dei eegni Schprooch unni as es dich ennich eppes koschte zellt. Ruf die Nummer 1-800-275-2583. Hindi: �या� द�: यिद आप िहदंी बोलते ह� तो आपके िलए मु�त म� भाषा सहायता सेवाएं �पल�� ह�। कॉल कर� 1-800-275-2583। German: ACHTUNG: Wenn Sie Deutsch sprechen, können Sie kostenlos sprachliche Unterstützung anfordern. Wählen Sie 1-800-275-2583. Japanese: 備考：母国語が日本語の方は、言語アシス

タンスサービス（無料）をご利用いただけます。

1-800-275-2583へお電話ください。

Persian (Farsi): صورت ه ب خدمات ترجمه، فارسی صحبت می کنيدتوجه: اگر

2583-275-800-1با شماره . رايگان برای شما فراھم می باشد .تماس بگيريد

Navajo: D77 baa ak0 n7n7zin: D77 saad bee y1n7[ti’go Diné Bizaad, saad bee 1k1’1n7da’1wo’d66’, t’11 jiik’eh. H0d77lnih koj8’ 1-800-275-2583.

Urdu:

توجہ درکارہے: اگر آپ اردو زبان بولتے ہيں، تو آپ کے لئے کال کريں ۔دستياب ہيں مفت ميں زبان معاون خدمات

.1-800-275-2583

Mon-Khmer, Cambodian: សូ�េ��្ត ចប់�រ�មណ៍៖ ្របសិនេបើអនកនិ�យ��ន-ែខមរ ��ែខមរ េនះជំនួយែផនក��នឹងមនផ្តល់ជូនដល់េ�កអនកេ�យ�តគិតៃថ្ល។ ទូរសពទេទេលខ 1-800-275-2583។

30 31


Language Assistance Services

Spanish: ATENCIÓN: Si habla español, cuenta con servicios de asistencia en idiomas disponibles de forma gratuita para usted. Llame al 1-800-275-2583 (TTY: 711).

Chinese: 注意：如果您讲中文，您可以得到免费的语言

协助服务。致电 1-800-275-2583。 Korean: 안내사항: 한국어를 사용하시는 경우, 언어

지원 서비스를 무료로 이용하실 수 있습니다.

1-800-275-2583 번으로 전화하십시오. Portuguese: ATENÇÃO: se você fala português, encontram-se disponíveis serviços gratuitos de assistência ao idioma. Ligue para 1-800-275-2583. Gujarati: �ચૂના: જો તમે �જુરાતી બોલતા હો, તો િન:��ુ� ભાષા સહાય સેવાઓ તમારા માટ� ��લ�� છે. 1-800-275-2583 કોલ કરો.

Vietnamese: LƯU Ý: Nếu bạn nói tiếng Việt, chúng tôi sẽ cung cấp dịch vụ hỗ trợ ngôn ngữ miễn phí cho bạn. Hãy gọi 1-800-275-2583. Russian: ВНИМАНИЕ: Если вы говорите по-русски, то можете бесплатно воспользоваться услугами перевода. Тел.: 1-800-275-2583. Polish UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-800-275-2583. Italian: ATTENZIONE: Se lei parla italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-275-2583. Arabic:

، فإن خدمات المساعدة اللغوية العربية ملحوظة: إذا كنت تتحدث اللغة .2583-275-800-1 اتصل برقملك بالمجان. متاحة

French Creole: ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-800-275-2583.

Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, magagamit mo ang mga serbisyo na tulong sa wika nang walang bayad. Tumawag sa 1-800-275-2583.

French: ATTENTION: Si vous parlez français, des services d'aide linguistique-vous sont proposés gratuitement. Appelez le 1-800-275-2583. Pennsylvania Dutch: BASS UFF: Wann du Pennsylvania Deitsch schwetzscht, kannscht du Hilf griege in dei eegni Schprooch unni as es dich ennich eppes koschte zellt. Ruf die Nummer 1-800-275-2583. Hindi: �या� द�: यिद आप िहदंी बोलते ह� तो आपके िलए मु�त म� भाषा सहायता सेवाएं �पल�� ह�। कॉल कर� 1-800-275-2583। German: ACHTUNG: Wenn Sie Deutsch sprechen, können Sie kostenlos sprachliche Unterstützung anfordern. Wählen Sie 1-800-275-2583. Japanese: 備考：母国語が日本語の方は、言語アシス

タンスサービス（無料）をご利用いただけます。

1-800-275-2583へお電話ください。

Persian (Farsi): صورت ه ب خدمات ترجمه، فارسی صحبت می کنيدتوجه: اگر

2583-275-800-1با شماره . رايگان برای شما فراھم می باشد .تماس بگيريد

Navajo: D77 baa ak0 n7n7zin: D77 saad bee y1n7[ti’go Diné Bizaad, saad bee 1k1’1n7da’1wo’d66’, t’11 jiik’eh. H0d77lnih koj8’ 1-800-275-2583.

Urdu:

توجہ درکارہے: اگر آپ اردو زبان بولتے ہيں، تو آپ کے لئے کال کريں ۔دستياب ہيں مفت ميں زبان معاون خدمات

.1-800-275-2583

Mon-Khmer, Cambodian: សូ�េ��្ត ចប់�រ�មណ៍៖ ្របសិនេបើអនកនិ�យ��ន-ែខមរ ��ែខមរ េនះជំនួយែផនក��នឹងមនផ្តល់ជូនដល់េ�កអនកេ�យ�តគិតៃថ្ល។ ទូរសពទេទេលខ 1-800-275-2583។


Discrimination is Against the Law

This Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. This Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

This Plan provides: Free aids and services to people with disabilities

to communicate effectively with us, such as:qualified sign language interpreters, and writteninformation in other formats (large print, audio,accessible electronic formats, other formats).

Free language services to people whoseprimary language is not English, such as:qualified interpreters and information written inother languages.

If you need these services, contact our Civil Rights Coordinator. If you believe that This Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with our Civil Rights Coordinator. You can file a grievance in the following ways: In person or by mail: ATTN: Civil Rights Coordinator, 1901 Market St reet , Ph i lade lph ia , PA 19103, By phone: 1-888-377-3933 (TTY: 711) By fax: 215-761-0245, By email: [email protected]. If you need help filing a grievance, our Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

IBC7756 (10/16)

32 PB

PO Box 13713Philadelphia, PA 19101-3713

www.ibxmedicare.com

For more informationFor updated information regarding plan providers, visit our website at www.ibxmedicare.com, or call theMember Help Team at 1-888-718-3333 (TTY/TDD: 711), seven days a week, 8 a.m. to 8 p.m. Please note thaton weekends and holidays from April 1 through September 30, your call may be sent to voicemail.

If you are not yet a member and have questions, please call 1-877-393-6733 or TTY/TDD: 711,seven days a week, 8 a.m. to 8 p.m. Please note that on weekends and holidays from April 1 throughSeptember 30, your call may be sent to voicemail. By calling this number you will be directed to a licensedsales agent.

Personal Choice 65 offers PPO plans with a Medicare contract. Enrollment in Personal Choice 65 MedicareAdvantage plans depends on contract renewal.

TruHearing® is a registered trademark of TruHearing, Inc., an independent company.

Vision benefits are underwritten by Keystone Health Plan East and administered by Davis Vision, an indepen-dent company.

An affiliate of Independence Blue Cross has a financial interest in Visionworks, an independent company.

The Independence OTC benefit is underwritten by Keystone Health Plan East/QCC and is administered byConvey Health Solutions, Inc., an independent company.

Telemedicine is provided by MDLIVE, an independent company.

To receive this document in an alternate format such as Braille, large print, or audio, please call1-877-393-6733 (non-members) (by calling this number you will be directed to a licensed sales agent) or1-888-718-3333 (members) (TTY/TDD: 711).

This information is not a complete description of benefits. Contact 1-877-393-6733 for more information.

Out-of-network/non-contracted providers are under no obligation to treat Personal Choice 65 Medical-OnlyPPO or Personal Choice 65 Rx PPO members, except in emergency situations. For a decision about whether wewill cover an out-of-network service, we encourage you or your provider to ask us for a pre-serviceorganization determination before you receive the service. Please call our customer service number orsee your Evidence of Coverage for more information, including the cost-sharing that applies toout-of-network services.

Benefits underwritten by QCC Insurance Company, a subsidiary of Independence Blue Cross —independent licensees of the Blue Cross and Blue Shield Association.

PC8888 (8/18)

PO Box 13713Philadelphia, PA 19101-3713

www.ibxmedicare.com

For more informationFor updated information regarding plan providers, visit our website at www.ibxmedicare.com, or call theMember Help Team at 1-888-718-3333 (TTY/TDD: 711), seven days a week, 8 a.m. to 8 p.m. Please note thaton weekends and holidays from April 1 through September 30, your call may be sent to voicemail.

If you are not yet a member and have questions, please call 1-877-393-6733 or TTY/TDD: 711,seven days a week, 8 a.m. to 8 p.m. Please note that on weekends and holidays from April 1 throughSeptember 30, your call may be sent to voicemail. By calling this number you will be directed to a licensedsales agent.

Personal Choice 65 offers PPO plans with a Medicare contract. Enrollment in Personal Choice 65 MedicareAdvantage plans depends on contract renewal.


Vision benefits are underwritten by Keystone Health Plan East and administered by Davis Vision, an indepen-dent company.


The Independence OTC benefit is underwritten by Keystone Health Plan East/QCC and is administered byConvey Health Solutions, Inc., an independent company.

Telemedicine is provided by MDLIVE, an independent company.

To receive this document in an alternate format such as Braille, large print, or audio, please call1-877-393-6733 (non-members) (by calling this number you will be directed to a licensed sales agent) or1-888-718-3333 (members) (TTY/TDD: 711).


Out-of-network/non-contracted providers are under no obligation to treat Personal Choice 65 Medical-OnlyPPO or Personal Choice 65 Rx PPO members, except in emergency situations. For a decision about whether wewill cover an out-of-network service, we encourage you or your provider to ask us for a pre-serviceorganization determination before you receive the service. Please call our customer service number orsee your Evidence of Coverage for more information, including the cost-sharing that applies toout-of-network services.

Benefits underwritten by QCC Insurance Company, a subsidiary of Independence Blue Cross —independent licensees of the Blue Cross and Blue Shield Association.

PC8888 (8/18)

For more informationFor updated information regarding plan providers, visit our website at www.ibxmedicare.com, or call the Member Help Team at 1-888-718-3333 (TTY/TDD: 711), seven days a week, 8 a.m. to 8 p.m. Please note that on weekends and holidays from April 1 through September 30, your call may be sent to voicemail.

If you are not yet a member and have questions, please call 1-877-393-6733 or TTY/TDD: 711, seven days a week, 8 a.m. to 8 p.m. Please note that on weekends and holidays from April 1 through September 30, your call may be sent to voicemail. By calling this number you will be directed to a licensed sales agent.

Personal Choice 65 offers PPO plans with a Medicare contract. Enrollment in Personal Choice 65 Medicare Advantage plans depends on contract renewal.


Vision benefits are underwritten by QCC Insurance Company and administered by Davis Vision, an independent company.


The Independence Blue Cross Over the Counter benefit is underwritten by QCC Insurance Company and is admin-istered by Convey Health Solutions, Inc., an independent company.

To receive this document in an alternate format such as Braille, large print, or audio, please call 1-877-393-6733 (non-members) (by calling this number you will be directed to a licensed sales agent) or 1-888-718-3333 (members) (TTY/TDD: 711).


Plans may offer supplemental benefits in addition to Part C benefits and Part D benefits.

Out-of-network/non-contracted providers are under no obligation to treat Personal Choice 65 Prime Rx PPO, Personal Choice 65 Medical-Only PPO, or Personal Choice 65 Rx PPO members, except in emergency situa-tions. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

Benefits underwritten by QCC Insurance Company, a subsidiary of Independence Blue Cross — independent licensees of the Blue Cross and Blue Shield Association.

PC8888 (8/18)

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